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Meals on Wheels had been delivering healthy meals to thousands of older adults in Portland, Oregon, for more than 50 years when a local hospital asked whether the group could cook similar meals for patients leaving the hospital after acute bouts of diabetes, heart disease and other chronic illnesses.
The answer was a resounding yes, according to Suzanne Washington, CEO of the local organization Meals on Wheels People. The group signed on with that Portland hospital five years ago and later agreed to provide meals for two others in the area.
Three years ago, data from the first hospital showed that patients with diabetes, congestive heart diseases and other chronic illnesses who received what are known as medically tailored meals were half as likely to be admitted to the hospital compared with those who didn’t receive meals, and the total cost of their care was substantially lower.
But medically tailored meals prescribed by hospital dieticians are still only a small fraction of the more than 8,000 meals the Portland nonprofit delivers daily.  
The federal government’s recent approval of Oregon’s request to modify its Medicaid program, the joint federal-state health insurance program for people with low incomes, could change that.
Oregon and other states have dabbled in Medicaid nutrition programs aimed at improving patients’ health in non-clinical, non-pharmaceutical ways, said Oregon Health Authority Director Patrick Allen in an interview with Stateline.
“But never have those efforts become a defined benefit in Medicaid that everyone who qualifies is entitled to receive,” he said. “This is a really big deal.”  
In the past decade, about a dozen states have cobbled together Medicaid and other funding to offer medically tailored meals and other nutrition programs on a limited basis. But none has made nutrition services available to substantial numbers of patients, as new efforts in several states would do.
The pandemic is showing the need for strong local agriculture.
Oregon’s $1.1 billion, five-year program will be available for youth with special needs and people experiencing homelessness. Along with housing and other social supports, the program will offer three medically tailored meals per day for up to six months for people with, or at risk of, diet-related illnesses.
Massachusetts also received federal approval under a wide-ranging $67 billion, five-year Medicaid waiver to provide food vouchers and medically tailored meals, as well as housing for children, pregnant women and women who have given birth in the past 12 months.
The Massachusetts waiver is groundbreaking because it allows Medicaid to pay for meals for the entire family — not just the patient, said Katie Garfield, director of whole person care at Harvard Law School’s Center for Law and Policy Innovation.
It’s well known that parents who receive medically tailored meals will share their food with children and older adults living in the household, reducing the effectiveness of those meals at healing the patient’s chronic condition, Garfield said.
“Allowing Medicaid to supply meals for the entire family is a major step forward,” she said.
Later this year, New York and Washington state are slated to receive approvals from the federal government for similar nutrition programs.  
A regular diet of fruits, vegetables and other nutritious food has long been shown to stave off and treat chronic illnesses and promote healing after surgery. And unlike pharmaceuticals, nutritious food does not have side effects.
It’s also well established that a deficit of nourishing food is a major cause of health disparities among people with low incomes and people of color, who suffer disproportionately from heart diseases, diabetes and other deadly and debilitating illnesses. 
Local nonprofit groups have been providing healthy meals and reporting improved health outcomes since the mid-1980s, when groups in New York and San Francisco began providing meals for HIV patients to boost weight gain and help manage their symptoms.
But with few exceptions, Medicaid, which covers nearly 90 million people, has failed to allow large-scale coverage of healthy meals as a way of preventing and managing chronic disease. That’s despite numerous studies showing that medically tailored meals cut both prescription drug and hospitalization costs.
A handful of states are working to change that. And they’re counting on big savings in their health care budgets in the process.
In addition to Oregon and Massachusetts, California, Colorado, Georgia, Maryland, Minnesota, New Jersey, New York, North Carolina, Pennsylvania and Washington are among the states that have experimented with a variety of Medicaid programs to help residents get the meals they need to prevent and treat diet-related diseases.
The Biden administration’s new emphasis on nutrition and health is expected to spur an expansion of limited Medicaid nutrition programs in states that already have them and encourage development of new food programs in states that don’t.
As part of a national strategy announced last month at a White House Conference on Hunger, Nutrition and Health, the Biden administration vowed to work with Congress to provide funding for medically tailored meals under Medicare, nutrition education and other nutrition programs under Medicaid, and improved access to nutrition and obesity counseling under both health care programs.
A major driver of health care costs, chronic diseases account for 81% of all hospital admissions, 91% of all prescriptions and 76% of all doctor’s visits, according to figures cited by several leading medical groups. More than half of Americans suffer from at least one diet-related chronic disease.
Research compiled by the Food is Medicine Coalition, a research and advocacy group, shows that only six months of dietary interventions such as medically tailored meals can reduce overall medical costs by 16%, or $220 per month per patient. That’s a result of 58% fewer emergency department visits, 49% fewer hospital admissions and 72% fewer nursing home admissions.
More states care what’s on the dinner plate.
According to the research, only 1 in 10 adults are meeting Department of Agriculture dietary standards for fruits and vegetables. That’s primarily because millions of people either can’t afford healthy food or live in neighborhoods where it isn’t available. Many also lack the education to know which foods should be included in a healthy meal and don’t have adequate kitchens to prepare them in, food and nutrition experts say. 
Alissa Wassung, executive director of the Food is Medicine Coalition, said nonprofits in the field are “feeding people who are the sickest of the sick, who are driving a lot of the health care costs that we’re trying to address.”
It makes sense that using medically tailored meals to avoid costly prescription drugs and frequent emergency department visits would save millions in health care spending, Wassung said.
But despite the mounting evidence, only a tiny fraction of those who could benefit from food assistance are getting it, advocates say.
In addition to meals, some states have encouraged local health care providers to write fruit and vegetable prescriptions for diet-related conditions, providing vouchers physicians can give patients to purchase the food they need. Other states contract with local nonprofits to deliver fruit and vegetable boxes to families, along with instructions on preparing healthy meals.
In California, where a Medicaid waiver for healthy food programs was approved in 2021, more than 14 million people are covered by the federal-state program; 15% of them have diabetes.
“They could be on insulin for the rest of their lives, or we could reduce or eliminate the need for medication through food-based interventions,” said Katie Ettman, food and agriculture policy manager for the social justice nonprofit, the San Francisco Bay Area Planning and Urban Research Association, or SPUR.
“When we think about the scale of the opportunity to improve health through food interventions,” Ettman said, “it only works when we have funding through the health care system.” She and other advocates want Medicaid and other public and private insurance carriers to make nutrition services a part of their basic coverage, equal to pharmaceuticals and clinical care.
Another missing link, said Harvard’s Garfield, is a health care infrastructure that includes dietary screening procedures, diagnosis and billing codes and staff protocols for prescribing diet interventions. Once that’s established, she said, food interventions could become as commonplace as prescribing medications or performing surgeries to treat chronic conditions.
Next, Garfield said, a network of local food providers must be established to work with the health care system like drug stores that fill prescriptions.  
In Oregon, Meals on Wheels People stands ready to cook and deliver thousands more medically tailored meals every day as soon as the Medicaid program is ready to pay for them, Washington said. 
An estimated 53.6 million people live outside an easy walk or drive to a full-service supermarket.
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